After-hours services in primary healthcare

Position

It is essential that patients with urgent medical issues have access to care when their usual general practice is unavailable. This care must be provided by dedicated after-hours services with an appropriately qualified workforce.

The RACGP has significant concerns about any model of primary healthcare delivery that either fragments care, compromises quality or contributes to health system inefficiencies. It is therefore crucial that patients can access care provided by after-hours services that is safe, high quality and where continuity of care is prioritised.

Accordingly, the RACGP is of the view that:

after-hours services that attract a Medicare Benefit Schedule (MBS) rebate, should only be provided by:

Specialist General Practitioners (GPs)

general practice registrars with appropriate supervision

medical practitioners actively working toward a Fellowship in general practicei

medical practitioners with more than ten years’ experience in Australian general practice.i

after-hours services should only be used when a patient's usual GP or general practice is not available in the after-hours period, and the patient has an urgent health concern that cannot be delayed until the next day

patients should preferably access after-hours services through their general practice, and general practices should provide their patients with information on how to access healthcare in the after-hours period

to facilitate clinical handover of care back to the patient's regular GP, a summary document detailing the clinical management of the patient shoud be forwarded to the patient's usual GP by the next day. Patients should be advised that they can opt-out of this process

dedicated after-hours services should only take appointments during the after-hours period, as defined by the Commonwealth.2

after-hours services must use appropriate triage processes to minimise the number of visits required.

dedicated after-hours services are not generally conventional general practices and therefore do not meet the RACGP’s definition of general practice. They act in a deputising capacity and provide a service that is supportive of the patient's regular general practice and therefore should be subject to specific regulation and accreditation

in order to enhance continuity of care, general practices have a formal agreement with an after-hours service provider

after-hours services should seek to establish and maintain formal connections or links with a patient’s usual GP or general practice.

Background

After-hours primary healthcare is defined as ‘accessible and effective care for people whose health condition is urgent and cannot wait for treatment until regular services are next available’.3 The Commonwealth defined after-hours period is between Monday to Friday from 6.00 pm to 8.00 am, Saturdays from midday, all day Sunday and all day on gazetted public holidays.2

General practice has a long history of working with after-hours service providers. When after-hours service providers are affiliated with an established general practice, the service can maintain continuity of care for a GP’s patient, while significantly reducing that GP’s need to provide after-hours care.

Issues

Education and training

Registration as a Specialist GP is the “gold standard” for any GP working in Australia, either within usual practice hours or after-hours. Providing after-hours primary care services is as challenging as clinic-based general practice. Doctors working for after-hours services must therefore have an appropriate level of education and clinical competency, as per the Fellowship of the RACGP (FRACGP) or Australian College of Rural and Remote Medicine (FACRRM) qualification.

The quality and safety of patient care is at risk in the absence of appropriately trained and experienced GPs providing primary care services in the after-hours period.

As such, after-hours services should only employ or contract:

Specialist General Practitioners

general practice registrars with appropriate supervision

medical practitioners actively working toward a Fellowship in general practice

medical practitioners with more than ten years’ experience in Australian general practice.1

The RACGP considers that the employment or placement of a general practice registrar by or in an after-hours service should be made in accordance with the RACGP Standards for general practice training.

Workforce arrangements that do not align with those described above will negatively affect the provision of quality patient care and can contribute to further emergency department presentations and/or follow up appointments with a GP.

It is not appropriate for after-hours services to engage doctors, registrars or Resident Medical Officers from specialties other than general practice.

After-hours services should therefore only be used when a patient’s usual GP or general practice is not available for an urgent health concern that cannot wait until regular services are next available. In such cases, it is preferred that patients access after-hours services that have a formal arrangement with their usual general practice.

Supporting continuity of care

Patients must be encouraged and supported to receive care from their regular GP or practice and only use dedicated after-hours services when this is not possible. However, when accessing after-hours services, the RACGP recommends that patients use services that have a formal agreement with their regular general practice.

Formal arrangements between general practices and after-hours services support continuity of care and the timely handover of clinical patient information to the patient’s regular GP. For this reason, the RACGP recommends that all after-hours services work directly with local general practices to develop appropriate continuity arrangements.

At a minimum, any formal agreement between a general practice and an after-hours service should detail how the after-hours service will:

remind all patients that after-hours services are a supplementary service

remind returning non-urgent patients that after-hours services should not be used to provide routine care

advise patients that having a regular GP is important for ongoing, comprehensive care

advise the patient that a summary document detailing their clinical management will be sent to their regular GP by the next day (and provide them with the option to opt-out of this arrangement)

ensure that the summary document is sent to the patient’s regular GP via secure communications

provide documentation detailing their clinical management directly to the patient (in situations where a the patient does not have a regular GP).

After-hours services and general practices should discuss and document other areas where continuity of patient care can be enhanced. During this process, general practices should also consider their obligations, including providing clinical information to the after-hours service regarding complex patients who may regularly require after-hours care.

Access

After-hours primary healthcare services play a vital role in ensuring that patients can access appropriate healthcare when they need it, and can alleviate demand on hospital emergency departments.

However, the RACGP considers that dedicated after-hours services should only schedule appointments during the after-hours period as defined by the Commonwealth. Patients should not be able to make appointments with an after-hours service in advance of the after-hours period.

Access for patients living in Residential Aged Care Facilities (RACFs)

After-hours services also have a vital role in preventing avoidable emergency department presentations and ensuring continuity of care for RACF residents. It is therefore vital that RACFs ensure that their patients are able to access either their preferred GP or an after-hours service provider.

Accreditation

The RACGP recognises that after-hours services are not conventional general practices. To ensure appropriate clinical and administrative governance, the RACGP therefore recommends that these services are accredited under specific standards related to after-hours services. Accreditation under these standards will also demonstrate a commitment to supporting quality care.

Triage

Appropriate triaging of patients is essential to avoid unnecessary use of after-hours services. In addition, many patients accessing care from an after-hours service will be unknown to the service.

The RACGP therefore strongly recommends that only suitably qualified staff employed by the after-hours service undertake triage. This includes GPs, nurses or other professionals trained in the appropriate protocols.

Advertising and marketing of after-hours services

After-hours services, like all other regulated health services, should adhere to the Medical Board of Australia’s Code of Conduct and the AHPRA Guidelines for advertising regulated health services.4 The guidelines indicate that under the Health Practitioner Regulation National Law (section 133), ‘a person must not advertise a regulated health service, or a business that provides a regulated health service in a way that directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services’.4

Patients can easily find out which after-hours services are available in their local area via their local general practice or a simple internet search. Given this, there is no valid reason for after-hours services to employ mass media marketing/advertising (via television, radio, billboards and print media) directly to the public. This type of advertising encourages the excessive and unnecessary use of after-hours health services, which is inappropriate.

i Doctors working under the conditions of the Approved Medical Deputising Service (AMDS) Program are considered to be working toward Fellowship with the RACGP.